照顧有跌倒風險的病人時，護理師應採取哪些措施？（選所有適合的）
Which actions should the nurse include when caring for a client who is at risk for falls? (Select all that apply.)
- AKeep the bed in the lowest position✓ 正解將病床保持在最低位置
- BPlace the call light within the client's reach✓ 正解將呼叫鈴放置在病人可觸及之處
- CEnsure the floor is free of clutter✓ 正解確保地板無雜物
- DApply physical restraints to prevent the client from getting up使用身體約束以防止病人起身
- EInstruct the client to use nonslip footwear✓ 正解指導病人穿著防滑鞋
預防跌倒是 NCLEX 的核心考點，重點在於建立一個低風險的物理環境。正確的護理介入措施應包含環境調整與病人自主性維護。選項 A、B、C、E 皆屬於標準的預防措施，能降低病人起身跌倒或滑倒的風險。身體約束（physical restraints）在美國醫療照護體系中被視為最後手段，僅在病人對自身或他人構成立即威脅，且所有替代方案（如床邊陪伴、警報器）皆無效時方可使用，絕不能用於常規預防跌倒。
Fall prevention is a core NCLEX concept focused on creating a low-risk physical environment. Correct nursing interventions include environmental modifications and preserving client autonomy. Options A, B, C, E are standard fall prevention measures that reduce risks of falls or slips. Physical restraints are viewed as a last resort in US healthcare, used only when the client poses an immediate threat to self or others and all alternatives (bedside companions, alarms) have failed. They should never be used for routine fall prevention.
美國醫院極度強調「無約束（restraint-free）」照護。在台灣，約束常作為預防跌倒的主動措施，但在美國，若未經醫師評估與嚴格記錄即進行約束，會被視為侵犯病人自主權（False Imprisonment），可能面臨法律風險。